Treating repetitive suicidal intrusions using eye movements: study protocol for a multicenter randomized clinical trial.

BACKGROUND: Suicide is a major public health problem, and it remains unclear which processes link suicidal ideation and plans to the act of suicide. Growing evidence shows that the majority of suicidal patients diagnosed with major depression or bipolar disorder report repetitive suicide-related images and thoughts (suicidal intrusions). Various studies showed that vividness of negative as well as positive intrusive images may be reduced by dual task (e.g. eye movements) interventions taxing the working memory. We propose that a dual task intervention may also reduce frequency and intensity of suicidal imagery and may be crucial in preventing the transition from suicidal ideation and planning to actual suicidal behaviour. This study aims a) to evaluate the effectiveness of an Eye Movement Dual Task (EMDT) add-on intervention targeting suicidal imagery in depressed patients, b) to explore the role of potential moderators and mediators in explaining the effect of EMDT, and c) to evaluate the cost-effectiveness of EMDT. METHODS: We will conduct a multi-center randomized clinical trial (RCT) evaluating the effects of EMDT in combination with usual care (n = 45) compared to usual care alone (n = 45). Participants will fill in multiple online batteries of self-report questionnaires as well as complete a semi-structured interview (Intrusion Interview), and online computer tasks. The primary outcome is the frequency and intrusiveness of suicidal imagery. Furthermore, the vividness, emotionality, and content of the suicidal intrusions are evaluated; secondary outcomes include: suicidal behaviour and suicidal ideation, severity of depression, psychological symptoms, rumination, and hopelessness. Finally, potential moderators and mediators are assessed. DISCUSSION: If proven effective, EMDT can be added to regular treatment to reduce the frequency and vividness of suicidal imagery. TRIAL REGISTRATION: The study has been registered on October 17th, 2018 at the Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR7563 ).

[Data-guided learning from suicidal incidents by using KEHR SUICIDE. A practice example in a Dutch mental health care facility]. / Datagestuurd leren van suïcidale incidenten met KEHR SUICIDE: GGz Eindhoven als praktijkvoorbeeld.

BACKGROUND: Specific and systematic data on health care providers' behaviour is needed to futher improve the care provided to suicidal patiënts in mental health care facilities.
METHOD: Explorative observational study of all suicidal incidents (n=50) that occurred in a Dutch mental health care facility over a one year period. Incidents were evaluated using KEHR SUICIDE, a questionnaire that assesses to what extent health care providers' conduct was compliant to the suicide practice guideline in the context of patients' suicidal behaviour. Associations between health care providers' and patients' features and guideline compliant behaviours of health care providers were calculated by logistic regression models.
RESULTS: Health care providers showed less guideline compliant behaviour when the patient had a psychotic, substance abuse or development disorder or had no axis 1 disorder. A positive association was found between guideline compliant behaviour and the extent to which the incident had been expected. CONCLUSION Guideline compliant behaviour of mental health care providers appears to be related to the axis 1 disorder of patients in a Dutch mental health care facility. Still, the application of guideline compliant behaviour concerning suïcide incidents shows room for improvement. KEHR SUICIDE is shown to be a helpful tool for multidisciplinary evaluation of suicidal incidents as it provides specific, ready-made information by which mental health care facilities can guide, examine and adjust suicide prevention policy. The outcomes provide hypotheses that may be examined in future research.

[Trends in suicidal behaviour in Dutch general practice, 1983-2013]. / Suïcidepreventie in de huisartsenpraktijk, 1983-2013* * Dit onderzoek werd eerder gepubliceerd in BMJ Open (2016;6:e010868) met als titel 'Trends in suicidal behaviour in Dutch general practice 1983-2013: a retrospective observational study'. Afgedrukt met toestemming. NIVEL Nederlands instituut voor onderzoek van de gezondheidszorg, Utrecht.Dr. D.P. de Beurs, klinisch psycholoog; dr.ir. M. Hooiveld, epidemioloog; dr.ir. J.C. Korevaar, epidemioloog; dr. G.A. Donker, huisarts-epidemioloog. Vrije Universiteit, afd. Klinische Psychologie, Amsterdam.Prof.dr. A.J.F.M. Kerkhof, klinisch psycholoog.Contactpersoon: dr. G.A. Donker (g.donker@nivel.nl).

OBJECTIVE: We investigated trends in suicidal behaviour as reported by Dutch general practices from 1983 to 2013. Also, we analysed the relationship with patient characteristics and with the financial crisis of 2008. DESIGN: Retrospective observational study. METHOD: We estimated age-adjusted and gender-specific trends in suicides (342) and attempted suicides (1614), as registered in 1983-2013 under ICPC code P77 by 40 Dutch general practices participating in the NIVEL Primary Care Database sentinel station. Secondary outcomes, on the basis of supplementary questions in the GP Information System (Huisartsen Informatie Systeem), were the relationship between suicidal behaviour, earlier treatments and patient characteristics. Also, we analysed separate frequencies for the periods 1983-2007 and 2008-2013. RESULTS: Join-point analyses revealed a significant rise in male suicides from 2008 (b = 0.32, SE = 0.1, p = 0.008), and an increase in male suicide attempts since 2009 (b = 0.19, SE = 0.04, p < 0.001). Female suicidal behaviour showed a steady decrease in 1989-2013: b = -0.03, SE = 0.007, p < 0.0001 for female suicide, b = -0.02, SE = 0.002, p < 0.001 for female attempts. Almost half of the suicidal patients had visited their GP one month before the event. In 31% of these patients, the GP had recognized suicidal behaviour. CONCLUSIONS: Since 2008, there was a rise in the male suicide rate while female suicide behaviour has continued to decline. Training in the early recognition of suicide ideation in depressive patients might improve suicide prevention in primary care.

[An evaluation of a new Dutch suicide prevention tool (KEHR); datadriven evaluation and learning]. / Pilotstudie naar kwalitatieve evaluatie van het handelen rond suïcide (KEHR); datagestuurd evalueren en leren.

BACKGROUND: Multidisciplinary evaluation of suicide cases effectively decreases the suicide rate in mental health care. A new suicide prevention tool (KEHR) can be used in this connection. KEHR has been developed on the basis of the Dutch multidisciplinary practice guideline on the assessment and treatment of suicidal behaviour. The guideline can serve as a frame of reference for the multidisciplinary evaluation of suicide cases. KEHR aims to provide professionals with a better method for preventing suicide. AIM: To describe and evaluate the recently developed KEHR strategy for reducing the number of suicide cases in mental health care. METHOD: Naturalistic and observational study. In the course of a year 22 out of 23 suicide cases that had occurred in the pilot institution were evaluated with the help of the KEHR system. Outcomes were discussed with members of multidisciplinary teams. Quantitative and qualitative methods were used in the evaluation process. RESULTS: Professionals from the main disciplines involved were very willing to use the new tool and were prepared to reflect on their views on the outcomes. The professionals were ready to learn from the suicide cases. Data collected with the tool provided information that can be used to improve guideline adherence. However, the use of KEHR did not lead automatically to the formulation of adjustments and improvements relating to suicidal patients. A specific procedure for improving individual and team performance needs to be developed and tested thoroughly. CONCLUSION: KEHR is a promising strategy for improving and enhancing the guideline on the diagnosis and treatment of suicidal behaviour of patients in mental health care. Special procedures need to be developed and studied in order to implement the improvements deemed necessary as a result of the pilot study. The KEHR tool (in the Dutch language) is accessible to mental health care workers after online registration (www.mijnkehr.nl).

[Risk factors and protective factors relating to suicide in the Netherlands and Flanders]. / Risicofactoren en beschermende factoren inzake suïcide in Nederland en Vlaanderen.

BACKGROUND: The suicide rate is 82% higher in the Flanders region of Belgium than in the Netherlands. AIM: To investigate to what extent Flanders and the Netherlands differ with regard to the risk factors and protective factors relating to suicide and attempted suicide. METHOD: By means of a structured postal questionnaire, we collected data on the following topics from 2999 Flemish and Dutch people between 18 and 64 years: mental well-being and earlier attempts to commit suicide, the help they had received and their intention to seek help for psychological problems, awareness of the mental health care available, satisfaction with the help received, and attitudes to suicide. RESULTS: The incidence of psychological problems and suicidality did not differ significantly between Flanders and the Netherlands. Compared to Flemish people, Dutch people with psychological problems had received more psychological help and more often expressed the intention to seek help in the future. Furthermore, the Dutch were better informed about mental health care, and patient satisfaction was higher in the Netherlands. Compared to the Flemish people, the Dutch had more positive and understanding attitude to suicide. CONCLUSION: In general, risk factors for suicide were similar in the Netherlands and Flanders. However, the Dutch were characterised by more protective factors. We attempt to explain these differences and suggest ways of improving suicidal prevention policy.

Psychological Distress Because of Asking about Suicidal Thoughts: A Randomized Controlled Trial among Students.

The aim of this study was to investigate the effect of the questions from the Beck Scale for Suicide Ideation on psychological well-being among healthy participants. In a randomized controlled study, 301 participants completed the same 4 questionnaires on psychopathology. The experimental group additionally answered 21 items of the Beck Scale for Suicide Ideation. The control group answered 19 items on Quality of Life. The experimental group showed a significantly smaller decrease of negative affect compared to the control condition. When analyzing participants with an increase in distress, 80% were part of the experimental group. For most participants, answering questions about suicide does not affect their mood. A small group of participants did react with some distress to the questions about suicide. As the questions about suicide were administered immediately before the questions about negative affect, the questions about suicide could have worked as a negative mood challenge. Future experimental research should further investigate the effect of questions about suicide among healthy participants, especially on the long term.

Attitudes and stigma in relation to help-seeking intentions for psychological problems in low and high suicide rate regions.

PURPOSE: Accessibility and availability of mental health care services are necessary but not sufficient for people to seek help for psychological problems. Attitudes and stigma related to help seeking also determine help seeking intentions. The aim of this study is to investigate how cross-national differences in attitudes and stigma within the general population are related to professional and informal help seeking intentions in low and high suicide rate regions. METHODS: By means of a postal structured questionnaire, data of 2999 Dutch and Flemish respondents between 18 and 65 years were gathered. Attitudes toward help seeking, perceived stigma, self-stigma, shame and intention to seek help were assessed. RESULTS: People in the Netherlands, where suicide rates are low, have more positive attitudes toward help seeking and experience less self stigma and shame compared to the people in Flanders, where suicide rates are relatively high. These attitudinal factors predicted professional as well as informal help seeking intentions. Perceived stigma was negatively associated with informal help seeking. Shame was positively associated with higher intention to use psychotropic drugs and perceived stigma was negatively associated with the intention to seek help from a psychotherapist in Flanders but not in the Netherlands. CONCLUSION: Help seeking for psychological problems prevent these problems to aggravate and it is assumed to be a protective factor for suicide. Our results stress the importance of the promotion of positive attitudes and the reduction of stigma within the general population to facilitate help seeking from professional providers and informal networks. Focusing on these attitudinal factors is believed to be a key aspect of universal mental health and suicide prevention policies.

[Suicide prevention via the internet and the telephone: 113Online]. / Suïcidepreventie via internet en telefoon: 113Online.

BACKGROUND: 113Online is a combination of a website and a telephone help-line for suicidal persons, their relatives and bereaved next of kin. The services it provides include crisis intervention, self-tests and brief psychotherapy. aim: To discover whether 113Online can in fact prevent suicidal behaviour ­ since it has now been in operation for more than a year. METHOD: We were able to obtain information about the visitors of the website, check on the usage of services provided by 113Online and study the results of the self-tests. RESULTS: The results for the first year indicated that there was a great need for anonymous online help for persons contemplating suicide. Scores for the self-tests showed that the website was visited by severely suicidal persons. It is surprising that so few of the users thereafter sought assistance from the conventional mental health care services. CONCLUSION: The 113Online seems to be a promising approach to suicide prevention. The online assistance reaches its target population and seems to fulfil needs that are not being met by the regular health care services.

[Older people who are 'weary of life': their expectations for the future and perceived hopelessness]. / Ouderen die 'klaar met leven' zijn: Toekomstverwachtingen en ervaren uitzichtloosheid.

There has been a debate for over a decade in The Netherlands about whether physicians should be allowed to provide assistance with suicide to older people who are 'weary of life'. Actual knowledge about these older people is missing in this debate. The purpose of this article is to explore and discuss the expectations older people who are 'weary of life' have of their future, and to what extent they perceive their suffering as hopeless. In this qualitative study, 31 older people who were 'weary of life' were interviewed. The results of this study show that most respondents who were 'weary of life' did not plan to end their life within a short time frame. The burden to their loved ones played a large role in their decision in addition to the awareness of still having reasons to live. Most respondents tried not to think too much about the future, and hoped death would come soon. Most respondents could not name a condition that would diminish their wish to die, that they also found desirable and feasible. The results of this study suggest that people who develop thoughts about death do so when they give up finding solutions to improve their situation.

Understanding why older people develop a wish to die: a qualitative interview study.

BACKGROUND: Quantitative studies in several European countries showed that 10-20% of older people have or have had a wish to die. AIMS: To improve our understanding of why some older people develop a wish to die. METHODS: In-depth interviews with people with a wish to die (n = 31) were carried out. Through open coding and inductive analysis, we developed a conceptual framework to describe the development of death wishes. Respondents were selected from two cohort studies. RESULTS: The wish to die had either been triggered suddenly after traumatic life events or had developed gradually after a life full of adversity, as a consequence of aging or illness, or after recurring depression. The respondents were in a situation they considered unacceptable, yet they felt they had no control to change their situation and thus progressively "gave up" trying. Recurring themes included being widowed, feeling lonely, being a victim, being dependent, and wanting to be useful. Developing thoughts about death as a positive thing or a release from problems seemed to them like a way to reclaim control. CONCLUSIONS: People who wish to die originally develop thoughts about death as a positive solution to life events or to an adverse situation, and eventually reach a balance of the wish to live and to die.

Wishes to die in older people: a quantitative study of prevalence and associated factors.

BACKGROUND: Death thoughts and wishes occur frequently among older people. In different European countries estimates of 10%-20% have been found. AIMS: To determine the prevalence and associated factors of death thoughts and wishes among older people in The Netherlands. METHODS: In The Netherlands 1794 people (58-98 years) were interviewed in 2005/2006 (Longitudinal Aging Study Amsterdam). RESULTS: 81.3% reported never having death thoughts/wishes; 15.3% reported having had such thoughts/wishes; 3.4% reported currently having a wish to die and/or a weakened wish to continue living. Of those with a current wish to die, 67% had depressive symptoms (vs. 32% of people with death thoughts/wishes ever and 9% of people who never had had death thoughts/wishes), and 20% suffered from a depressive disorder (vs. 5% if death thoughts/wishes ever; 0.3% if never death thoughts/wishes). In a multivariate analysis, a current wish to die was associated with having depressive symptoms, a depressive disorder, lower perceived mastery, financial problems, loneliness, small network, involuntary urine loss, being divorced, and having a speech impediment. CONCLUSIONS: Practical implications for health-care professionals are that they should be aware that in certain situations older people are more likely to develop a wish to die, and that a wish to die does not necessarily mean that someone has a depressive disorder. Nevertheless, it should serve as a trigger to investigate and to treat depression if present.

Recruiting end-of-life cancer patients in the Netherlands for a study on suffering and euthanasia requests.

BACKGROUND: In the Netherlands, GPs performed euthanasia or physician-assisted suicide (EAS) in ∼1 of 10 end-of-life cancer patients in their care. Of all explicit requests for EAS directed at GPs, ∼44% resulted in EAS. However, the suffering of patients who do and do not request EAS has never been studied. An important barrier for such research is the low prevalence of end-of-life cancer patients per practice (on average two/year). We studied whether it is possible to recruit end-of-life cancer patients, following-up for requests for EAS (if any), in an interview study in general practice, whether selection occurred and which were the threats and opportunities to recruitment. Our target was to recruit at least 50 patients. METHODS: Characteristics of all eligible patients were monitored. RESULTS: One in every three eligible patients were recruited by 44 GPs in a 3-year inclusion period, resulting in 64 patients in the interview study with follow-up until death. The prevalence of explicit requests for EAS was higher (27%; P = 0.026) in the interview sample, and the presence of a depressed mood according to the GP was lower (5%; P = 0.013) than in the sample with eligible but not participating patients. CONCLUSIONS: Recruitment of slightly more than the minimal target number of end-of-life cancer patients in this study in general practice was realized. Monitoring of all eligible patients permitted to evaluate the selection which occurred. Recruitment through GPs who were direct professional colleagues of one of the researchers was a positive recruitment factor.

Depression and explicit requests for euthanasia in end-of-life cancer patients in primary care in the Netherlands: a longitudinal, prospective study.

BACKGROUND: In the Netherlands, many (45%) cancer patients die at home, in the care of GPs. About 1 out of 10 end-of-life cancer deaths is hastened by GPs through euthanasia or physician-assisted suicide. However, the relationship between depression and requests for euthanasia has never been prospectively studied directly in primary care. OBJECTIVE: This study aimed to assess the prevalence of depression in end-of-life cancer patients requesting euthanasia in primary care, as well as to assess the relationship between depression and requesting euthanasia. METHODS: Primary care patients with incurable cancer and an estimated life expectancy of half a year or shorter were interviewed every 2 months, using standardized psychometric instruments. Also, non-recruited eligible patients were monitored. RESULTS: Out of 258 eligible patients, 76 patients were recruited, of whom 64 patients were followed up until death. Of these, 27% (n = 17) explicitly requested euthanasia. One patient suffered from major depression. According to the depression subscale of the Hospital Anxiety and Depression Scale, 47% of the patients who explicitly requested euthanasia versus 28% of those without an euthanasia request suffered from a depressed mood at inclusion; the difference was not significant (P = 0.2). Corresponding figures for the last interview before death were 40% and 41% (P = 0.6). CONCLUSIONS: Major depression was not a major factor in explicit requests for euthanasia in end-of-life cancer patients in primary care. Further depressed mood was not associated with explicitly requesting euthanasia in this patient group, although statistical underpower cannot be ruled out in this small sample.

Impulsive but fatal self-poisoning with pesticides among South Asians in Nickerie, Suriname.

BACKGROUND: Intentional self-poisoning with pesticides is a serious problem in many developing countries. It is a commonly used method among South Asians all over the world. AIMS: To describe the circumstances and characteristics of suicides in Nickerie, e, in order to gain insight into why South Asians commonly use self-poisoning. METHODS: An exploratory psychological autopsy study was conducted among 19 survivors of 13 suicides in the Nickerie district in Suriname. RESULTS: Impulsivity plays an important role in self-poisonings, as well as aggression and easy accessibility of pesticides. CONCLUSIONS: Possible answers to the question why South Asians often use self-poisoning as a method for suicide may be found in culture, upbringing, styles of communication and genetics. However, more research is needed to further explore these hypotheses.

[The quality of online suicide prevention in the Netherlands and Flanders in 2007]. / De kwaliteit van onlinesuïcidepreventie in Nederland en Vlaanderen in 2007.

BACKGROUND: The internet can provide valuable support for persons with suicidal tendencies. By means of the Google search engine we found and categorised 153 Dutch websites dealing with suicide. The websites relating to suicide prevention (n = 23) were scored for quality against a list of 17 quality features. The standard of the Dutch online suicide prevention websites is not optimal. Improvement is needed particularly in the field of e-help, and interactive possibilities need to be extended.

[The no-suicide contract: a risky ritual]. / Het non-suïcidecontract: een riskant ritueel.

In spite of former research the preventive value of the no-suicide contract is still uncertain. Making up a no-suicide contract should be considered as a risky ritual because there is a chance for underestimation of the actual risk. Less risky alternatives are: systematic risk assessment, the commitment to treatment statement and the delay or reconsideration agreement.

[Prevention of post-discharge suicide: an inventory]. / Preventie van suïcide na ontslag uit klinische opname: een inventarisatie.

BACKGROUND: Research has shown that the first months after discharge from psychiatric inpatient care is a high risk period for suicide. However, there has been very little research into the prevention policies that mental health care centres pursue in order to reduce this risk. AIM: To draw up an inventory of the preventive activities that mental health services undertake to reduce the risk of suicide by psychiatric patients discharged from inpatient treatment. METHOD: Fifteen mental health care providers of 10 different departments of 4 mental health care organisations in the province North-Holland were asked in a personal interview about the policy of their institution regarding the prevention of suicide after discharge. results One out of 10 locations had a standard policy for the prevention of suicide after discharge from psychiatric care. Four locations had an informal policy and 5 an ad hoc policy. Differences were found in the views of mental health care providers regarding suicide prevention and the responsibility of mental health care centres for the prevention of post-discharge suicide. CONCLUSION: Only half of the mental health institutions employed a preventive policy with regard to post-discharge suicide. So far, the possibilities for prevention have not been fully utilised.

The factorial structure of the Suicide Intent Scale: a comparative study in clinical samples from 11 European regions.

Although the Suicide Intent Scale (SIS) is a widely used instrument in research on suicidal behavior, comparative research on the latent structure of the SIS has been neglected. To determine whether a general factor model of the SIS is supported, alternative factor models of the SIS were evaluated comparatively in 11 clinical samples. The SIS was applied as part of a structured clinical interview to patients after an episode of non-fatal suicidal behavior. The samples were drawn from 11 study centers within the frame of the WHO/EURO multicenter study on suicidal behavior. Three different two-factor and two three-factor models of the SIS were examined in each sample using principal component analysis with orthogonal Procrustes rotation. The factorial structure of the 'subjective part' of the SIS (items 9-14) was strongly supported, whereas an acceptable model fit for the 'objective part' was not found. Possible future revisions of 'objective' SIS items may be worth consideration. As a limitation, the results of the study might not generalize to other samples that use different definitions of non-fatal suicidal behavior.

[Suicide among Surinamese migrants in the Netherlands by ethnicity]. / Zelfdoding onder Nederlandse Surinamers naar etniciteit.

BACKGROUND: Research into attempted suicide among Surinamese migrants in the Netherlands has revealed a high incidence of suicidal behaviour among young Hindustani women. Due to a lack of data on the ethnicity of Surinamese migrants residing in the Netherlands, there has not yet been any quantitative study of the relationship between ethnicity and suicide. AIM: To measure the differences between the rates of suicide mortality in the group of Surinamese migrants in the Netherlands and the corresponding rates in the native Dutch population, taking into account ethnicity, age and gender. METHOD: The study is based on all the cases of suicide among the Surinamese migrants resident in the Netherlands between 1996 and 2005. Ethnicity was inferred from residents' surnames. To determine the size of the groups at risk, a sample of Surinamese migrants resident in the Netherlands was taken. RESULTS: Suicide rates within the group of Surinamese migrants are particularly high among Hindustani men and young Creole men and are considerably higher than among native Dutch men. Suicide rates for Surinamese women are considerably lower than for Surinamese men and in most cases do not differ significantly from the suicide rates for native Dutch women. CONCLUSION: The incidence of suicide is particularly high among Surinamese men in the Netherlands. The high incidence is not restricted to Hindustani men.